Summer 2017 Health Form Break Down The health and safety of campers are our primary concern. As such, we review and update our Health Forms each year to reflect changes made in Maryland State Youth Camp regulations; in addition to following all health and safety guidelines set forth by the American Camping Association, Inc. and Girl Scouts of the USA. For 2017, remember WE HAVE GONE ONLINE! Please create an account or update last year s with CampDoc and upload all your camper s forms to your profile. Please complete the forms applicable to your camper and upload to your CampDoc profile no later than May 2, 2017. Which Health Forms do you need? r Health Exam ALL Trip and Travel Resident Campers attending camps that are leaving property during their week at camp are required to have a physical examination performed by a licensed health-care provider within 12 months prior to attending Resident Camp. These camps include: Kayak ATTACK!, Underwater Explorers, Theater in the Woods, Rocks, Ropes and Rappelling, Guppy Gulch, Pennsylvania Expedition, Outdoor Explorer, Holiday at Harpers Ferry, CIT/WIT I&II and ikayak. o Please note the 12-month deadline this deadline is set by the American Camping Association, Inc. We will accept copies of physical forms perform by schools /sports groups within the timeframe. r Medication Administration - ALL Campers who will be bring medications to camp. The term Medications includes ALL prescription and over-the-counter medications, vitamins and supplements. This form allows you to list all prescription and non-prescription medications (including emergency meds) that your camper will bring with them during their stay at camp in one place. All medications must be brought to camp in their original packaging or prescription containers. This year: o REMEMBER! A health-care provider must sign the form ALL medications that are brought to camp. Without written authorization from a health-care provider, no medication can be administered during your campers stay. i.e. package says 200 mg Ibuprofen - adults and children 12 and over; take 1 tablet every 4-6 hours. Health-care provider may write alternative directions stating camper may take 2 200 mg tablets every 4-6 hours. o Camp Conowingo s Health Center will NOT be providing: Ibuprofen (i.e. Advil, Motrin); Pseudoephedrine (i.e. Sudafed); or Bismuth Subsalicylate (Pepto-Bismol). If your camper will need these medications, please include these medications and any additional medications the Medication Administration Form. r Specialized Health Care (Form 4) - ALL Campers who have severe asthma or severe allergic reactions requiring medications such as rescue inhalers and epi pens. This form allows you and your health-care provider to outline your camper s specific allergy action plan and medication(s) for reaction intervention. r Copy of health Insurance cards ALL CAMPERS - Please provide a copy of your health insurance card, front and back.
To Parent(s)/Guardian(s): Complete this section ONLY. Program Camper is attending: Dates camper will attend camp: from to MM/DD/Year MM/DD/Year Camper Name: Date of Birth:. Age on arrival at Camp: First M.I. Last MM/DD/Year Camper Home Address: Custodial parent(s)/guardian(s) Name(s): ; Phone Number: #1 ( ) ; Home Cell Work Phone Number: #2 ( ) ; Home Cell Work ( Parent(s)/guardian(s) stop here. Rest of form to be completed by medical personnel. MEDICAL PERSONNEL: Please review the Summer Camp Health History Form, Medication Administration Form (if applicable) and Specialized Health Care Form (if applicable), and then complete all remaining sections of this form. Attach Additional information if needed. Date of visit. Physical exam done today: Yes No (If No, date of last physical exam: ) MM/DD/Year MM/DD/Year ACA accreditation standards specify physical exam within last 12 months. Weight: lbs Height: ft in Blood Pressure: / Pulse: Allergies: To foods (list): To medications (list): No Known Allergies To the environment (ins ect s ti ngs, hay fe ver, etc. lis t): Other allergies (list): Describe previo us reacti ons : Diet and nutrition: Eats a regular diet. Has a medically prescribed meal plan or dietary restrictions (describe): Current Treatment: None The camper is undergoing treatment at this time for the following conditions (describe below): Other: Treatments/therapies to be continued at camp (describe below): None needed Permission for non-prescription medication: The following non-prescription medications are commonly stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Please indicate below which medications the camper should NOT have. (Camper will receive nonprescription medications as outlined by manufacturer unless a written statement from camper s health-care provider authorizes a different dosage). Mark medications a camper should NOT have: r Acetaminophen (i.e. Tylenol) r Aloe Vera Gel r Antacid (i.e. Tums) r Antiseptic Wipes (Benzalkonium Chloride) r Bacitracin Ointment r Calamine lotion r Coppertone Water Babies Sunscreen Lotion, SPF 50 r Diphenhydramine oral tablet (i.e. Benadryl) Health Exam-Trip & Travel Campers To Parent(s)/Guardian(s): Trip and Travel Campers Complete the top of this form, and give this form to your camper s health-care provider for review at least 12 months before attending camp. If applicable, also complete the Medication Administration Form and Specialized Health Care Form. Once ALL forms are completed - Make a copy for your records. Upload to your CampDoc profile, with a copy of your Health Insurance Card (front and back) by May 2, 2017. r Halls Honey-Lemon cough drops ** r Hydrocortisone 1% cream r Vosol Ear Drops (i.e. Swim Ear) Camp WILL NOT HAVE: Ibuprofen (i.e. Advil, Motrin) Pseudoephedrine (i.e. Sudafed) Bismuth Subsalicylate (Pepto-Bismol) If camper requires these medications, or alternative dosages, please include the medications and any dosages changes on the Summer Camp Medication Administration Form (Form 3). In my opinion, the camper is able to participate in an active camp program. Yes No With limitations or restrictions If the camper requires limitations or restrictions, what do you recommend? (describe below, attach additional information if needed) Camper Name (For Camp Use) Session(s) /Group/Cabin
I have reviewed the Health Exam Form and have discussed the camp program with the camper s parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above.) Signature of Licensed Medical Personnel:. Printed name:. Title/Degree:.. Address: Telephone: ( ) Fax: ( ) Date form completed MMMM/DD/Year General Information: Program Camper is attending: Dates camper will attend camp: from to MM/DD/Year MM/DD/Year Camper Name: Date of Birth: Age on arrival at Camp: First M.I. Last MM/DD/Year Camper Home Address: Medications at Camp Conowingo By Law ALL medications, (prescription and non-prescription must be brought to camp in their original container. DO NOT pre-dispense, place in a daily pill holder, wrap in other materials, or ask us to dispense by other than doctor s orders. Do not pack medications in your camper s luggage! All medications must be turned in during check-in at camp or at the bus stop and kept in the Health Center at camp. (Emergency medications will be kept with a camper s unit or with camper. Please complete the Specialized Health Care Form) Medicine times are directly after breakfast, lunch and before dinner and at bedtime, unless otherwise directed. At least ONE dose of a prescription medicine MUST be given to camper at home before bringing to camp. No trials or sample medications will be accepted. A list of medications commonly stocked in the camp Health Center is provided on the Summer Camp Health History (Form 1). These are the only nonprescription medications the camper can have prior written consent by a health care provider. All other medications, including prescriptions, vitamins, supplements, and over-the-counter medications MUST be included below. A health-care provider must sign the form for medications to be administered at camp. Prescription medications: All prescription medicines must be in original container with pharmacy label with prescription number, date filled, prescribing physician s name, name of medication, directions for use, and the patient s name. All prescription medicines must be listed on the chart below in order for the camper to receive the medication. Medications cannot be expired. Sample or Trial medications from a doctor s office cannot be administered while at camp. Medication Administration To Parent(s)/Guardian(s): If applicable, complete this form and the Specialized Health Care Form. A health-care provider must sign the form for all prescription and non-prescription medications. Once ALL forms are completed - Make a copy for your records. Upload to your CampDoc profile, with a copy of your Health Insurance Card (front and back) by May 2, 2017. Non-prescription medications: All non-prescription medications, including over-the-counter medications, vitamins and supplements must be in original manufacturer s container labelled with the dosage instructions, expiration date and campers name. All non-prescription medications must be listed on the chart below in order for the camper to receive the medication. F2-1 Camper Name (For Camp Use) Session(s) /Group/Cabin
Must be completed for campers bringing medication to camp (Over) F3-1 Camper Name
Additional Comments: Licensed Medical Professional/Prescriber section: Necessary for ALL prescription and Non-prescription medications administered at camp Name: Title: Address:. Telephone: ( ) Fax: ( ) Signature: Date: Licensed Medical Professional/Prescriber Stamp Parent/Guardian Section: I request the authorized youth camp operator or staff to administer the medication or supervise the camper in self-administration if authorized as prescribed by the above authorized prescriber. I certify that I have legal authority to consent to medical treatment for the child named above, including the administration of medication at Camp Conowingo located at 46 Camp Shadowbrook Rd, Conowingo MD, 21918. I understand that at the end of the authorized period, an adult must pick up the medication, otherwise it will be discarded. I authorize camp personnel to communicate with the authorized prescriber as allowed by HIPAA. Parent/Guardian Name: Telephone 1: ( ) Telephone 2: ( ) Signature: (For additional medications, attach a second copy of this form) Date: Specialized Health Care To Parent(s)/Guardian(s): If applicable, complete this form and the Medication Administration Form. A health-care provider must sign. Once ALL forms are completed - Make a copy for your records. Upload to your CampDoc profile, with a copy of your Health Insurance Card (front and back) by May 2, 2017. Camper Name (For Camp Use) Session(s) /Group/Cabin Camper Name (For Camp Use) Session(s) /Group/Cabin F3-2 General Information: Program Camper is attending: Dates camper will attend camp: from to MM/DD/Year MM/DD/Year Camper Name: Date of Birth: Age on arrival at Camp: First M.I. Last MM/DD/Year Camper Home Address: To parents/ guardians: Complete this form with your camper s health-care provider. While at camp, all of emergency medicines (EPI pens, rescue inhalers, etc.) will remain with a camper s unit/group. These medications must be accounted for at all times while at camp. The Unit Leader will carry necessary medications in the Unit s First Aid kit that will be remain with the campers unit through the day. Please ensure your camper is able to self-administer the medication with an adult s supervision. EMS will be always be called if epinephrine is given whether or not the camper manifests any symptoms of anaphylaxis shock. Allergy Action Plan Allergy to:. Symptoms Medication Received If a food allergen has been ingested, but no symptoms:.................................. EpiPen Mouth Itching, tingling, or swelling of lips, tongue, mouth:................................ EpiPen Skin Hives, itchy rash, swelling of the face or extremities:................................ EpiPen Gut Nausea, abdominal cramps, vomiting, diarrhea:..................................... EpiPen Throat = Tightening of throat, hoarseness, hacking cough:.............................. EpiPen Lung = Shortness of breath, repetitive coughing, wheezing:............................. EpiPen Heart = Thready pulse, low blood pressure, fainting, pale, blueness:.................... EpiPen Other: EpiPen If reaction is progressing (several of the above areas affected), give:................... EpiPen Dosage Epinephrine: Inject intramuscularly EpiPen OR EpiPen Jr (circle one)
. Antihistamine: Give medication name dose route Other: Give medication name dose route Asthma Action Plan Triggers: Medication Name: Dosage/Strength: Type of Device: Time Given: (For what symptoms) Time Interval/ Repeating Dose: Medication Name: Dosage/Strength: Type of Device: Medication Name: Time Given: (For what symptoms) Time Interval/ Repeating Dose: Medication Name: Dosage/Strength: Type of Device: Medication Name: Time Given: (For what symptoms) Time Interval/ Repeating Dose: If camper is taking more than one medication, list sequence in which medications are to be taken: 1. 2. 3. Signature of Licensed Medical Personnel:. Date: Address:. Telephone: ( ) Fax: ( ) I understand that I must supply the camp with the equipment/supplies listed above and I hereby authorize the treatment/procedures described above to be administered by Camp Health Care Staff. In addition, I understand that I and/or my physician will be called if a question arises about my daughter's procedure Signature of Parent/Guardian:. Date: F4-1 Camper Name (For Camp Use) Session(s) /Group/Cabin